After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should:
a. Give supplemental oxygen with a small face mask.
b. Encourage the parents to hold the infant.
c. Palpate the infant's clavicles.
d. Perform a complete newborn assessment.
C
Because of the shoulder dystocia, the infant's clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up.
The Apgar indicates that no respiratory interventions are needed.
The infant needs to be assessed for clavicle fractures before excessive movement.
A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant.
You might also like to view...
A patient has an elevated BUN and creatinine. The patient has been prescribed digoxin (Lanoxin) for heart failure. What aspect of care is the priority regarding this patient?
A) The patient should be taught to increase sodium in her diet. B) The dose should be increased when her heart rate is below 60. C) The dose should be decreased in this patient. D) The dosage should be 1.0 mg PO daily.
A nurse working in a rehabilitation center notices clients frequently asking for something to drink. Which response indicates the use of creativity in finding a solution to this problem?
1. Calling local beverage distributors to inquire about service pricing 2. Asking all employees to write down their ideas about a solution 3. Determining what type of drinks most clients might want 4. Encouraging clients to bring a drink from home
The nurse is caring for a patient who is receiving an infusion of botulinum antitoxin after consuming botulinum toxin in contaminated food. The patient has developed double vision, slurred speech, and upper body muscle weakness
The patient's spouse asks the nurse what the antitoxin will do. Which response is correct? a. "The antitoxin is an antidote to the botu-linum toxin." b. "This medication helps restore strength in weakened muscles." c. "This infusion will help prevent further nerve damage." d. "The antitoxin will reverse the symptoms within a couple of days."
When the immediate post-MI client complains about the high-fiber diet and being encouraged to drink water, the nurse would inform the client that the purpose of such a diet is to
a. create a high-bulk, soft stool. b. lower cholesterol levels. c. maintain bowel health to decrease gas. d. promote easy digestion.